<script type="text/javascript">
nowtab = 2;
function checkFillForm(){
	doPost('/User/saveFillCaptchaInfo','fillinfo_f','msgReturnDiv');
	return false;
}
</script>
<form id="fillinfo_f" action="/user/saveFillCaptchaInfo" method="post">
	<input type="hidden" name="code" value="<?php echo $data['code'];?>" />
	<div style="line-height:30px;color:red"><strong>请确认中奖信息(全部必填)：</strong></div>
	<table cellpadding="0" cellspacing="0" style="font-size:12px;line-height:28px">
		<tr>
		<td width="100px"  valign="top">验证码： </td><td><b style="font-weight:bold;font-size:14px"><?php echo $data['code'];?></b><br />
		<span class="hint">请记录验证码，凭验证码到柜台即可领取奖品。<br/>您可以随时在“我的开心赚宝-未领取宝贝”中查看验证码。</span>
		</td>
		</tr>

		<tr>
		<td width="100px"  valign="top">真实姓名： </td><td><input type="text" name="realname" value="<?=empty($data['real_name'])?'':$data['real_name']?>"></input><br />
		<span class="hint">领取礼品时需经过实名认证，请填写真实姓名</span>
		</td>
		</tr>


		<tr>
		<td valign="top">手机号码： </td><td><input type="text" name="phone" value="<?=empty($data['phone'])?'':$data['phone']?>"></input><br />
		</td>
		</tr>

		<tr>
		<td valign="top">生日： </td><td><input type="text" name="birthday" value="<?=empty($data['birthday'])?'':$data['birthday']?>"></input><br />
		<span class="hint">如：1984-01-01</span>
		</td>
		</tr>

		<tr>
		<td valign="top">省份： </td><td><input type="text" name="province" value="<?=empty($data['province'])?'':$data['province']?>"></input><br />
		</td>
		</tr>

		<tr>
		<td valign="top">城市： </td><td><input type="text" name="city" value="<?=empty($data['city'])?'':$data['city']?>"></input><br />
		</td>
		</tr>

		<tr>
		<td valign="top">地址： </td><td><input type="text" name="address" value="<?=empty($data['address'])?'':$data['address']?>"></input><br />
		</td>
		</tr>

		<tr>
		<td valign="top">邮编： </td><td><input type="text" name="zipcode" value="<?=empty($data['zipcode'])?'':$data['zipcode']?>"></input><br />
		</td>
		</tr>

		<tr>
		<td>&nbsp;</td><td><input type="button" onclick="return checkFillForm()" value="确认保存信息"/>&nbsp;&nbsp;&nbsp;&nbsp;<span id="msgReturnDiv" style="color:red"></span></td>
		</tr>

		<tr>
		<td>提示：<td>凭验证码去柜台领取奖品，一个验证码仅可领取一份奖品。<br/>开心赚宝承诺，绝不会将您的个人信息外泄。</td>
		</tr>
	</table>
</form>
